Low Risk Chest Pain

The Shownotes on Low Risk Chest Pain

The management of low risk chest pain in the US is founded on a number of tenets:

If low risk chest pain patients are sent home and they have unstable angina, they will do worse than if we admitted them

Provocative testing will identify patients who are safe for discharge

A positive stress test identifies patients who will have benefit from PCI

PCI is the standard of care for UA/NSTEMI as it reduces patient important adverse events

The problem is that all of these are false. But I wouldn’t expect you to believe me; instead listen to the masters of Emergency EBM: David Newman and Ashley Shreves of SMART EM. Here is what we cover:

If low risk chest pain patients are sent home and they have unstable angina, they will do worse than if we admitted them

But where is the evidence? The one trial I can find (see below) shows no difference.

Stress testing will risk stratify these patients, so we know which ones are safe for discharge

Low risk chest pain patient (as deemed by EM Physician judgment) with 2 sets negative and non-specific EKGs has a risk of <1% already, so what does the stress test add to this w/u?

A positive stress test identifies patients who will have benefit from PCI

Nope, not in low risk patients…Most of the time the cards folks will get a positive stress and still not intervene. Instead the patient gets started on aspirin with instructions for lifestyle modification. It might even wind up worsening adverse events b/c patients will have false positives and may get unnecessary caths.

PCI is the standard of care for UA/NSTEMI as it reduces patient important adverse events

If there is any benefit at all, it is for the outcome of the need for unplanned revascularization at 6-12 months. Ashley discovered that actually, for UA patients (troponin negative) there may be increased mortality in order to get that benefit

For all of the evidence behind this podcast, immediately go to these SMART EM Podcasts:

Perhaps, you want a summary of all of the evidence presented on stress testing from those Smart EM Episodes

Literature Mentioned in this Podcast

The only study I can find that directly addresses the question of what happens if you discharge patients is by Pope et a. [10770981]. There was no statistically significant increase in mortality in the patients who were mistakenly sent home with MI or ACS despite a rather questionable attempt at retrospective risk adjustment. This was the study that the AHA predicated most of its recommendations that UA is a dangerous disorder to miss and patients must be tested or admitted.